Patient DOB MRN

Facility Encounter Date

History Chief Complaint is required in ALL documentation

Components Criteria
HPI (History of Present Illness)
Status of 3 chronic problems Status of Status of Status of 3 Status of 3
1 2 3 1-2 1-2 Chronic Chronic
Chronic Chronic Conditions Conditions
Conditions Conditions
OR
Choose Elements OR OR OR OR
Quality Location Duration Severity
Timing Context Modifying factors Brief Brief Extended Extended
Associated Signs/Symptoms 1-3 1-3 ≥4 ≥4
Elements Elements Elements Elements
ROS (Review of Systems) NA
Constitutional ENT Eyes Pertinent Extended Complete
CV Skin/Breasts to Problem (Pertinent to (Pertinent and all
problem and related systems)
Resp Endo
other related
GI GU Heme/Lymph systems)
1
MS Neuro Psych 2-9 Total 10 Total
Allergy/Immunology
PFSH (Past Medical, Family Social History) NA NA
Past History (Illnesses, Surgeries, Injuries) Pertinent *Complete
Past Family (Diseases, Hereditary illnesses)
Social (Review of current, past activities) 1 Area 2-3 Areas
*Complete PFSH
3 history areas for ALL NEW Patients PROBLEM EXPANDED DETAILED COMPREHENSIVE
2 history areas for ALL Follow Up/Established Visits FOCUSED PROBLEM
OR Patients seen in Emergency Department
FOCUSED
ALL Criteria for selected level MUST be MET or EXCEEDED

Examination
Exam description 1995 Guideline 1997 Guideline Type of Exam
Limited to affected body area or 1 1-5
organ system Body Area or Bulleted Items PROBLEM FOCUSED
Organ System
Affected body area/organ system 6-11 or more
and other symptomatic or related 2-7 EXPANDED PROBLEM
organ systems
FOCUSED
Extended exam of affected body 12-17 or more
areas/organ systems and other 2-7 for 2 or more systems DETAILED
symptomatic or related organ
systems
General Multi-System ≥8 18 or more
for 9 or more systems COMPREHENSIVE
Complete Single Organ System Not Defined Refer to Guideline
See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements

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Patient DOB MRN
Facility Encounter Date

A. Complexity of Medical Decision Making

Number of Diagnoses or Treatment Options
Number x Points = Result
Problem (Status) Number Points Result
Self-limited or minor (stable, improved or worsening) Max = 2 1
Est. problem (to examiner) stable, improved 1
Est. problem (to examiner) worsening 2
New problem (to examiner) no additional workup planned Max = 1 3
New problem (to examiner) additional workup planned 4
Circle corresponding answer on Line A of Final Result for Complexity Total

B. Amount and/or Complexity of Data Reviewed

Reviewed Data Points
Review and/or Order of lab tests 1
Review and/or Order of tests in the radiology section of CPT 1
Review and/or Order of tests in the medicine section of CPT 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtain history from someone other than the patient 1
Review and summarization of old records and/or obtaining history from someone other than the patient and/or 2
discussion of case with another health care provider
Independent visualization of image, specimen or tracing (NOT simply review of report) 2
Circle corresponding answer Line B of Final Result for Complexity TOTAL

C. Risk of Complications, Morbidity and/or Mortality

Choose highest risk level and select corresponding risk level on line C in Final Result for Complexity
Risk Presenting problems Dx procedures ordered Management options
Min 1 minor or self-limited Venipuncture, CXR, EKG, EEG Rest, elastic bandages

Low 2 or more minor
1 stable chronic problem
Acute uncomp illness/injury
Mod Mild exac  1 chron prob
2 stable chron prob
Acute illness + systemic Sx
Acute complicated injury
High Sev exac, 1 chron prob
Acute or chronic illness
posing threat to life/limb
Abrupt change neuro status
Physiol tests NOT under stress
Non CV imaging with contrast
Superficial needle biopsies
Physiologic tests under stress
Dx endoscopies NO risk factors
Deep needle or incisional bx
CV imaging + contrast
Obtain fluid from body cavity
CV imaging + contrast, risk factors
Card electrophysiologic studies
Dx endoscopies + risk factors
Discography
OTC drugs, PT, OT
IV fluids without additives
Minor surgery NO risk factors
Minor surgery + risk factors
Elective major surgery
Prescription drug therapy
Therapeutic nuclear medicine
IV fluids + additives
Elective maj surg + risk factors
Emergency major surgery
Parenteral controlled sub
Rx requiring intense monitoring
DNR or de-escalation of care

Final Result for Complexity of Medical Decision Making

The column with 2 or 3 circles determines overall complexity of Medical Decision Making
A Number Tx Options 1 or less 2 3 4
Minimal Limited Multiple Extensive
B Amount of Data 1 or less 2 3 4
Minimal Limited Multiple Extensive
C Highest Risk Minimal Low Moderate High
Decision Making Level SF Low Moderate High

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Patient DOB MRN
Facility Encounter Date

OVERALL OUTPATIENT ENCOUNTER LEVEL

New Office / Consult / ER Established Office
Requires 3 components within shaded area Requires 2 components within shaded area
History PF EPF D C C Minimal PF EPF D C
ER: PF ER: EPF ER: EPF ER: D ER: C problem
that may
Exam PF EPF D C C
not
PF EPF D C
ER: P ER: EPF ER: EPF ER: D ER: C
require
Complexity SF SF L M H presence SF L M H
Medical ER: SF ER: L ER: M ER: M ER: H of
Decision physician

LEVEL I II III IV V I II III IV V

PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive
SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity

OVERALL INPATIENT ENCOUNTER LEVEL

Initial Hosp Encounter or Observation Subsequent Inpatient or Follow Up
History D or C C C PF EPF D
Exam D or C C C PF EPF D
Complexity Medical SF / L M H SF / L M H
Decision
LEVEL I II III I II III
PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive
SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity

Time If ALL responses regarding time are “Yes”, billing may be based on Time
“If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter,
time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment,
instructions, compliance, risk reduction or discussion with another health care provider.”
Does documentation reveal total time? Must be face-to-face (Outpatient or Yes No
Inpatient)
Does documentation discuss the content of counseling or coordination of care? Yes No
Does documentation reveal that more than half the time was spent on counseling or Yes No
coordination of care?

References
1997 Guidelines for Evaluation and Management Services
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

HGSAdministrators Documentation Worksheet

www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf

Evaluation and Management Coding and Documentation Reference Guide

Trailblazer Health Enterprises, LLC

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